To the Editor: Compulsive sexual behavior involves excessive or uncontrolled behavior and sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial entanglements (1). Compulsive sexual behavior can involve both conventional sexual practices and deviant patterns of arousal, including pedophilia. Few treatments have been described, although Kafka (2) reported the use of serotonin reuptake inhibitors and antiandrogen drugs. We report the case of a patient with pedophilia who responded to combination treatment with carbamazepine and clonazepam.
Mr. A, a 56-year-old married man, was referred for treatment of pedophilia. He had been preoccupied with sexual fantasies about children since his teen years, but only in the last 10 years had his preoccupation led him to seek out sporadic contact with prepubescent boys and girls (usually between ages 3 and 14 years). His behavior with older children (boys and girls) involved penile penetration, although with younger children, he mostly rubbed against them to the point of orgasm. He reported that his fantasies were repetitive, and while he experienced a sense of shame, he felt unable to control his fantasies: "I’ve become a monster." Despite his impulsive behaviors, he had never been arrested, and he reported no other paraphilic behaviors, such as exhibitionism. The behavior led to considerable dysphoria and guilty ruminations, accompanied by panic attacks. In addition to these contacts, he usually masturbated two to three times each week.
Mr. A’s only complaint was occasional headaches, which were treated with analgesic medication. He had no history of other psychiatric symptoms or impulsive behaviors, such as trichotillomania, compulsive buying, kleptomania, pathological gambling, or intermittent explosive disorder. There was no history of drug or alcohol abuse. He was gainfully employed and active in his church. Married 30 years, Mr. A reported normal sexual relations with his wife until his disturbing thoughts about children eventually led him to distance himself emotionally and sexually from her.
Because of Mr. A’s dysphoria and anxiety relating to his sexual behavior, he was given carbamazepine, 300 mg/day, and clonazepam, 2 mg/day. His only side effects were transient sedation and headache. He reported significant improvement over the course of a month, with near-complete resolution of inappropriate sexual cognitions and behavior. His doses were gradually lowered to 0.5–1.0 mg/day of clonazepam and 200 mg/day of carbamazepine for long-term maintenance. The improvement has now persisted for over 1 year.
Kafka (2) has written extensively on the use of serotonin reuptake inhibitors and antiandrogens in patients with compulsive sexual behaviors to reduce sexual preoccupation and decrease hypersexuality, but to our knowledge, this is the first report of a patient with pedophilia responding to the combination of carbamazepine and clonazepam. This particular combination was selected to pharmacologically target the patient’s impulsivity and mixed anxiety and depression. We cannot, of course, exclude the possibility that the patient experienced a placebo response. Nonetheless, our experience suggests that this medication combination may be beneficial to other patients as well.